Nokea
A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?
- A. Use the Z-track technique to administer the medication.
- B. Administer the medication with a 27-gauge 1/2-inch needle.
- C. Inject the medication at least 5 cm (2 in) from the umbilicus.
- D. Give the medication without aspirating prior to injection.
Correct Answer: A
Rationale: The correct answer is A: Use the Z-track technique to administer the medication. This technique helps prevent leakage of the medication into surrounding tissues by sealing the medication in the muscle. The Z-track method involves pulling the skin laterally before injecting the medication, then releasing the skin after the injection. This creates a zig-zag path that closes after the needle is withdrawn, reducing the risk of irritation or staining at the injection site. Choice B is incorrect because the needle size for IM injections in adults is typically 22-25 gauge and 1-1.5 inches long. Choice C is incorrect as IM injections should be administered at least 2.5 cm (1 inch) away from the umbilicus. Choice D is incorrect because aspiration (pulling back on the plunger to check for blood return) is not recommended for IM injections due to the risk of tissue trauma.
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A nurse is caring for a client who started taking amitriptyline 6 days ago. The client reports that the medication is not helping. Which of the following responses should the nurse make?
- A. I will ask your provider to increase the dose of the medication.
- B. You will need to take this medication on an empty stomach for it to be more effective.
- C. You will need to wait a couple of weeks to feel the therapeutic effect of the medication.
- D. I will inform your provider so they can prescribe a different medication.
Correct Answer: C
Rationale: The correct response is C: "You will need to wait a couple of weeks to feel the therapeutic effect of the medication." Amitriptyline, a tricyclic antidepressant, typically takes 2-4 weeks to start showing its full therapeutic effects. It is important for the nurse to educate the client about the delayed onset of action to manage expectations. Option A is incorrect because increasing the dose prematurely can lead to adverse effects. Option B is incorrect as taking it on an empty stomach is not necessary for its efficacy. Option D is incorrect as switching medications without giving the current one a fair trial may not be appropriate.
Vital Signs
Laboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
The nurse should first address the client's ___ followed by the client's ___. (Options: Hgb level, Blood pressure, temperature, Hct level, abdominal findings, potassium level)
- A. Hgb level
- B. Blood pressure
- C. temperature
- D. Hct level
- E. abdominal findings
- F. potassium level
Correct Answer: B,F
Rationale: Action to Take: B, F; Potential Condition: Hypovolemia; Parameter to Monitor: Blood Pressure, Potassium Level.
Rationale:
1. Blood pressure should be addressed first to assess perfusion status and hemodynamic stability.
2. Potassium level should be monitored next due to potential electrolyte imbalances in hypovolemia.
3. Hgb, Hct, and abdominal findings are important but secondary to addressing perfusion and electrolyte balance.
4. Temperature is not typically the initial concern in hypovolemia.
A nurse is reviewing a list of current medications for a client who is starting therapy with furosemide. Which of the following medications should the nurse identify as being contraindicated?
- A. Levothyroxine
- B. Lithium carbonate
- C. Albuterol
- D. Cetirizine
Correct Answer: B
Rationale: The correct answer is B: Lithium carbonate. Furosemide can cause sodium depletion, leading to increased lithium levels and potential lithium toxicity. Levothyroxine (A) is not contraindicated with furosemide. Albuterol (C) may increase the risk of hypokalemia when used with furosemide but is not a contraindication. Cetirizine (D) does not have significant interactions with furosemide.
A nurse is reinforcing teaching with a client who has a prescription for sildenafil to treat erectile dysfunction. Which of the following statements by the client indicates an understanding of the teaching?
- A. This medication will protect me from sexually transmitted diseases.
- B. I will avoid eating fatty foods, while I take this medication.
- C. I should take this medication twice each day.
- D. I can expect to have constipation while I take this medication.
Correct Answer: B
Rationale: The correct answer is B. Eating fatty foods can delay the absorption of sildenafil, so avoiding them can help the medication work effectively. Choice A is incorrect because sildenafil does not protect against STDs. Choice C is incorrect as sildenafil is usually taken as needed, not twice daily. Choice D is incorrect as constipation is not a common side effect of sildenafil.
A nurse is reinforcing teaching with a client who has a prescription for nystatin oral suspension. Which of the following instructions should the nurse include in the teaching?
- A. Swish the medication in your mouth.
- B. Use a straw when taking this medication.
- C. Take the medication with meals.
- D. Drink at least 8 ounces of water after taking the medication.
Correct Answer: A
Rationale: The correct answer is A: Swish the medication in your mouth. Nystatin oral suspension is an antifungal medication used to treat oral thrush, a fungal infection in the mouth. By swishing the medication in the mouth before swallowing, it allows the medication to come into contact with the affected areas in the mouth, ensuring better efficacy. Using a straw (choice B) may not be effective as it may not reach all areas of the mouth. Taking the medication with meals (choice C) may interfere with the absorption of the medication. Drinking water after taking the medication (choice D) is not necessary for its effectiveness.